Risikobasert behandling ved tumor thyroidea

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Risikobasert behandling ved tumor thyroidea

• Til norsk ved Thorleif Ellingsen
• overlege , ØNH Sykehuset Østfold
• Med tillatelse av Ashok Shaha , M.D. , F.A.C.S.
• Head and Neck Service
• Memorial Sloan-Kettering Cancer Center
• New York , N.Y.

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• Professor Ashok Shaha

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Thyroid Literature
Medline
Thyroid disease 136,053 Thyroid tumors 33,554

• New Paper on Thyroid Disease Every 3 Hours
• New Paper on Thyroid Cancer Every 8 Hours

Thyroid Google search 36 million
Thyroid Cancer Google search 21 million
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Thyroid Cancer Incidence Mortality1974 to
2004
Thousands
Overall
Women
Men
Mortality
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Thyroid Cancer
A Unique Human Neoplasm

• Age is the most important prognostic factor

• No stage III IV cancers in pts below 45

• Multicentricity of thyroid cancer is frequent
  
• no prognostic impact
• Microscopic tumor laboratory cancer

• Nodal metastasis has no impact on outcome

• Impact of extrathyroidal spread

• Grade of the tumor histologic poorly
• differentiated features

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Differentiated Cancer of the Thyroid
Prognostic Factors
Age
Age
Grade
Metastasis
Extension
Extension
Size
Size
AGES (Mayo Clinic)
AMES (Lahey Clinic)
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Low Risk Thyroid Cancer
Comparison of Risk Group Definitions
Dead of Disease
Total Cases
AGES (1946 - 1970)
Mayo Clinic Pap Ca
Low Risk 737 (86) 2
High Risk 121 (14) 46
AMES (1961 - 1980)
Lahey Clinic Pap Fol Ca
Low Risk 737 (86) 2
High Risk 121 (14) 46
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Differentiated Thyroid Cancer
Rx Expectations

• 80 do well after lobectomy alone

• 5 die, regardless of Rx

• 15 require aggressive surgery RAI

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Differentiated Cancer of the Thyroid
Risk Group Definitions
Low Risk
Intermediate Risk
High Risk
Age (years) lt45 lt45 gt45 gt45
Distant mets M0 M M0 M
Tumor size T1/T2 T3/T4 T1/T2 T3/T4
(lt4cm) (gt4cm) (lt4cm) (gt4cm)
Histology Papillary Follicular Papillary Folli
cular Grade /or /or high grade high
grade
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Risk Stratification in Thyroid Cancer

• Low
• Intermediate
• High

Low Risk Pt Low Risk Tumor
(lt45)
Low Risk Pt High Risk Tumor
High Risk Pt Low Risk Tumor
(gt45)
High Risk Pt High Risk Tumor
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Differentiated Thyroid Cancer 1980-1980
SURVIVAL Lobectomy vs. Total
Low Risk Group
PROPORTION SURVIVING
100
99
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Differentiated Thyroid Cancer
Prognostic Factors
AGES AMES APES DAMES GAMES MACIS
Mayo Clinic Lahey Clinic Swedish MSKCC
Mayo 1987 group Clinic 1993
Age Age Age DNA ploidy Grade Metastasis
Grade Metastasis Ploidy Age
Age Age (distant)
Extra- Extra- Extra- Metastasis Mets
Completeness capsular capsular capsular of
resection tumor tumor tumor
Extent Extra- Invasion capsular
tumor
Size Size Size Size Size
Size
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Indications for Total Thyroidectomy

• Grossly palpable disease in both lobes

• High risk patient with high risk tumor

• Radiated patient

• Young patient with large nodal metastasis
• to facilitate RAI

• Patient with distant metastasis likely to
• require RAI

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Eur J Cancer 21(2)305-313, 1988.
Thyroid Cancer The Case for Total Thyroidectomy
ORLO H. CLARK, KENNETH LEVIN, QI-HUA
ZENG, FRANCIS S. GREENSPAN ALLAN SIPERSTEIN
Veterans Administration Medical Center The
University of California, San Francisco, U.S.A.
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The fact that total thyroidectomy can be
performed safely does not necessarily mean that
it is indicated in all patients with thyroid
cancer...
An operation not worth doing is not worth doing
well.
Collin Thomas Chapel Hill
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Thyroid Carcinoma with Extrathyroid Extension
Treatment Failure
Percent
plt0.0001
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The staging system for papillary carcinoma of
the thyroid invading the trachea, based on the
histologic extent of invasion
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Histology
Papillary Ca - Increased aggressiveness
associated with

• Solid/trabecular

• Diffuse sclerosing type

• Tall cell

• Columnar cell (very aggressive)

• Insular tumor

• Areas of poorly differentiated ca

• Areas of undifferentiated ca

• Extensive angioinvasion

• Extensive capsular invasion

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Tall Cell Thyroid Cancer
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Insular Thyroid Cancer
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Cancer of the Thyroid
Papillary
Poorly differentiated
Anaplastic
Follicular
Tall cell, Insular, etc.
Good
Bad
Ugly
80
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5
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Biological Markers

• Ploidy

• EGF receptor status

• Presence of oncogenes and tumor suppressor
• gene mutation

• Adenylate Cyclase response to TSH

• p53

• Bax, P27, Galectin, Telomerase

• BRAF

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Exploiting biology for management
Differentiation
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Prognostication in thyroid cancer
Genomic instability
Size, DM, ETE, Mortality
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Genetic abnormalities in 63 papillary thyroid
cancers detected by CGH
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Aberrations in PTC vs. other cancers
Cases with aberrations detected by CGH
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Genetic Progression of Thyroid Cancer
TCV
PTC
PD-TC
ATC
1 p gain 2q loss 4 loss 6p gain 6q loss 9q
gain 13q loss 17q gain
5q gain 7q gain 8q gain 8 loss 9 loss 12q gain
5 q loss
1p loss 11 loss 12 loss 16q gain 18 loss 20 gain
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1q21 Amplification
1q21 gene over expression
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45
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Prediction of disease-free survival
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Histological Correlates
Percent Positive Scans
Well
Moderate
Poorly
Undiff
Degree of Tumor Differentiation
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Prognostic Implication of 18FDG PET
Wang et el. JCEM 851107-1113, 2000
n125 (14 deaths)
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Paradigm Shift in Detection of Recurrent Thyroid
Cancer

• RAI Scan

• CT, MRI

• Thyroglobulin

• Ultrasound Ultrasound-guided FNA

• FDG PET

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Thyroid Cancer
20 yr survival
Treatment
Good
Lobectomy. Appropriate surgery based on extent of
disease.
99
Low
Total thyroidectomy. Select extent of
thyroidectomy based on extent of disease. RAI in
select cases.
Bad
85
Intermediate
Total thyroidectomy. RAI. Ext RT in
selected cases.
Ugly
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High
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Surgeon
Complications
Institutional philosophy
Endocrinologist
Thyroid ca patient (Internet)
THE BOSS!
Nuclear Physician
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Commonplace clinical problems in surgery are
approached in diametrically opposite ways - by
surgeons with similar training backgrounds,
having read the literature but interpreting the
available information differently, based on
unique personal experience, vision or surgical
prejudice.
-- Richard Simmons
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Thyroid Cancer
A Tip for Surgeons
Invite an Endocrinologist for Drinks Dinner!